Review the Santos Family Case Study interactive media activity. If

1

Biopsychosocialspiritual Assessment

The biopsychosocialspiritual assessment and intervention plan are to be written as though they will be presented to a court or interdisciplinary team. That is, they are to be written in a professional format, rather than as a course paper. This format will be discussed in the courseroom.

Biopsychosocialspiritual Assessment Format

I. Identifying Information A. Who was the provider in the session (your name and credentials) B. Location of session, who was present (did the client come alone, with a

family, friend, or partner), date, and length of session C. Confidentiality and Informed consent (written and verbal) D. Demographic information: age, date of birth, sex, ethnic group, current

employment, marital status, physical environment/housing: nature of living circumstances (apartment, group home or other shared living arrangement (who lives in the home), homeless); neighborhood.)

E. Referral information: referral source (self or other), reason for referral. Other professionals or indigenous helpers currently involved.

F. Data sources used in writing this assessment: interviews with others involved (list dates and persons), tests performed, other data used.

II. Presenting Problem

A. Description of the problem, and situation for which help is sought as presented by the client. Use the client’s words. What precipitated the current difficulty? What feelings and thoughts have been aroused? How has the client coped so far?

B. Who else is involved in the problem? How are they involved? How do they view the problem? How have they reacted? How have they contributed to the problem or solution?

C. Past experiences related to current difficulty. Has something like this ever happened before? If so, how was it handled then? What were the consequences?

III. Background History

A. Developmental history: from early life to present (if obtainable) B. Family background: description of family of origin and current family. Extent of

support. Family perspective on client and client’s perspective on family. Family communication patterns. Family’s influence on client and intergenerational factors.

C. Intimate relationship history D. Educational and/or vocational training

2

E. Employment history F. Military history (if applicable) G. Use and abuse of alcohol or drugs, self and family

Treatment and Outcome of treatment (i.e. out patient or in-patient) H. Medical history: birth information, illnesses, accidents, surgery, allergies,

disabilities, health problems in family, nutrition, exercise, sleep I. Mental Health history: previous mental health problems and

treatment, hospitalizations, outcome of treatment, family mental health issues.

J. Personal Events: deaths of significant others, serious losses or traumas, significant life achievements (Note: these events can be positive or challenging in nature)

K. Cultural background: race/ethnicity, primary language/other languages spoken, significance of cultural identity, cultural strengths, experiences of discrimination or oppression, migration experience and impact of migration on individual and family life cycle.

L. Spirituality: denomination, church membership, extent of involvement, religion, perspective, special observances.

IV. Assessment

A. Psychosocial / Developmental History: 1. Examples: Family of origin history 2. Education/vocational background 3. Relationship history/ marital status 4. Trauma and Abuse history (has client ever been sexually, emotionally, or

physically abused? To their knowledge, have they ever sexually, physically, or emotionally abused another person?)

5. Legal History (current or past legal concerns) 6. Relevant Religious/spiritual/ cultural factors

B. Current Substance Use 1. Tobacco: 2. Alcohol: 3. Drugs: 4. OTC Supplements

1. For each of the above: a. First time they used? How much for each? Last time

they used and how much? Difficulty stopping or cutting back? Impacting work, family, or other obligations? Others asking client to cut back? Medical provider asking them to cut back? Cravings, withdrawal history etc.

C. Military History 1. Disciplinary issues 2. Characterization of discharge and reason 3. Deployment History (combat zone or other, location, etc)

3

4. Blast exposure/ combat related TBI 5. Combat exposure/ deployment related PTSD

D.

1. What is the key issue or problem from the client’s perspective? From the worker’s perspective?

2. 2. How effectively is the client functioning? 3. 3. What factors, including thoughts, behaviors, personality issues,

environmental circumstances, stressors, vulnerabilities, and needs seem to be contributing to the problem(s)? Please use systems theory with the ecological perspective as a framework when identifying these factors.

4. 4. Identify the strengths, sources of meaning, coping ability, and resources that can be mobilized to help the client.

5. 5. Assess client’s motivation and potential to benefit from intervention.

E. Pain Assessment (location of pain in the body and intensity of pain, measurable on a scale of 0 to 10 with 0 being no pain and 10 being extreme unbearable pain)

F. Suicidal and homicidal assessment (assess for imminent risk: plan, intention, means, access, etc.)

1. Related Safety plans 2. All assessments should document that you reviewed the nearest resources

(ER or hospital) in case of a change in mental health status or emergency even if a client is not suicidal, homicidal or experiencing perceptual abnormalities.

G. Medical Concerns and conditions.

1. Diagnosis of medical concerns 2. Medications, dose, schedule, reason for medication 3. Primary Care Provider name and contact information 4. Any specialist contact information and name

1. Documentation of other providers involved allows you to pursue consent if needed and allows you to make referrals for any medical care concerns as needed and helps ensure care is comprehensive

5. Any physical, intellectual, or mental health disabilities H. Psychiatric history

1. Past hospitalization 2. Family history or mental illness or substance abuse 3. Past mental health treatment

I. Protective Factors (Examples below and will be different for each client)

1. Willing to engage in treatment 2. Contracts for safety 3. Has safety plan/knows how to access resources

4

4. Feels attached to family/friends

J. Protective Factor Statement if Applicable: Client is willing to engage in treatment, contracts for safety and has safety plan/knows how to access resources, feels attached to family/friends, denies current plan or intent. The patient stated in the case his mental status should change he would contact his command.

K. Full Mental Status Examination (Use the format below)

1. Orientation: Alert and Oriented to person place and time? 2. Grooming: Adequate/Appropriate, Inadequate/Inappropriate and how 3. Behavior: Cooperative, easy to engage appropriately interactive, good eye

contact or other? 4. Speech: Normal rate, rhythm, prosody and tone or other? 5. Psychomotor: No Abnormalities or psychomotor agitation or retardation 6. Mood: Euthymic or other? 7. Affect: Congruent or other? 8. Thought process: Linear, logical and goal directed or other? 9. Thought content: Appropriate, Denied A/VH, no evidence of delusions or

psychosis or other? 10. Suicidal Ideation: Denies. No plan/intent or other? 11. Homicidal Ideation: Denies. No plan/intent. Or other? 12. Insight: Intact or poor? 13. Judgment: Not impaired or impaired? If Impaired, what actions are you

taking to address safety? 14. Concentration and Attention: Within normal limits or not? 15. Memory: Intact or other? 16. Impulse Control: Intact or poor? 17. Intelligence: Average, below, or above?

L. Diagnosis (in a paragraph following the diagnosis with DSM5 coding, include all

symptoms that support the diagnosis according to the DSM5 as the client is experiencing)

M. Treatment plan/intervention considerations 1. Does the treatment plan match the diagnosis? 2. Is the treatment plan and intervention suggested evidence based and not

your opinion? 3. Are there goals that are developed between you and the patient or client

that are measurable? 4. What is the schedule of therapy? When and how often will they return? 5. What is the target plan for termination and are the goals and plan

measurable to show the intervention and goals were met through clear measurements so you do not terminate and abandon a client etc.?

5

6. Does the plan in place allow you to make clear steps in each session to show a linear path to completion and not just notes of what you talked about in each session?

V. Intervention

A. Work with the client to identify a minimum of two goals. Goals should be stated as the outcome of a successful intervention (For example: Ms. Jones will live in stable and safe housing).

B. For each goal, identify two objectives that will result in goal achievement. Objectives are the steps you (or your client) take to get to the goal (For example: A. The social worker will provide a referral for Emergency Housing by sending an email with the required form by 03/18/2016. B. Ms. Jones will provide the social worker with a copy of her identification card and her two most recent pay stubs by 03/15/2016).

C. Identify possible obstacles and tentative approaches to prevent or address them. Your Intervention Plan should look like this:

• Goal: Ms. Jones will live in stable and safe housing o Objective: The social worker will provide a referral for Emergency Housing by

sending an email with the required form by 03/18/2016. o Objective: Ms. Jones will provide the social worker with a copy of her

identification card and her two most recent pay stubs by 03/15/2016.

Your Go-To Guide

Documentation IN BEHAVIORAL HEALTH CARE

of Care, Treatment, or Services

Joint Commission Resources Mission The mission of Joint Commission Resources (JCR) is to continuously improve the safety and quality of health care in the United States and in the international community through the provision of education, publications, consultation, and evaluation services.

Disclaimers JCR educational programs and publications support, but are separate from, the accreditation activities of The Joint Commission. Attendees at Joint Commission Resources educational programs and purchasers of JCR publications receive no special consideration or treatment in, or confidential information about, the accreditation process. The inclusion of an organization name, product, or service in a JCR publication should not be construed as an endorsement of such organization, product, or service, nor is failure to include an organization name, product, or service to be construed as disapproval.

This publication is designed to provide accurate and authoritative information regarding the subject matter covered. Every attempt has been made to ensure accuracy at the time of publication; however, please note that laws, regulations, and standards are subject to change. Please also note that some of the examples in this publication are specific to the laws and regulations of the locality of the facility. The information and examples in this publication are provided with the understanding that the publisher is not engaged in providing medical, legal, or other professional advice. If any such assistance is desired, the services of a competent professional person should be sought.

© 2018 The Joint Commission

Joint Commission Resources Oak Brook, Illinois 60523 http://www.jcrinc.com

Joint Commission Resources, Inc. (JCR), a not-for-profit affiliate of The Joint Commission, has been designated by The Joint Commission to publish publications and multimedia products. JCR reproduces and distributes these materials under license from The Joint Commission.

All rights reserved. No part of this publication may be reproduced in any form or by any means without written permission from the publisher. Requests for permission to make copies of any part of this work should be sent to [email protected].

ISBN (print): 978-1-63585-043-7 ISBN (e-book): 978-1-63585-044-4

Printed in the USA

For more information about The Joint Commission, please visit http://www.jointcommission.org.

Acknowledgments Content Development Manager: Lisa K. Abel Senior Editor: Phyllis Crittenden Project Manager: Lisa M. King Associate Director, Publications: Helen M. Fry, MA Associate Director, Production and Meeting Support: Johanna Harris Executive Director, Global Publishing: Catherine Chopp Hinckley, MA, PhD

Reviewers Joint Commission Division of Healthcare Improvement Julia Finken, BSN, MBA, Executive Director, Behavioral Health Care Accreditation Program; Peggy Lavin, LCSW, Senior Associate Director, Business Development, Behavioral Health Care Accreditation Program; Kathryn Petrovic, MSN, RN-BC, Senior Associate Director, Standards Interpretation Group; Peter Vance, LPCC, CPHQ, Field Director, Department of Accreditation and Certification Operations; Merlin Wessels, LCSW, Associate Director, Standards Interpretation Group

Joint Commission Division of Healthcare Quality Evaluation Lynn Zielinski, MLA, Project Director, Department of Standards and Survey Methods

iii

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ix

CHAPTER 1

Overview of Behavioral Health Care Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . 1

SECTION SETS The Basics of Behavioral Health Care Documentation CONCISE CONCEPTS Documentation of Care, Treatment, or Services . . . . . . . . . . . . . . . . . . 2 INSTRUCTIVE INFOGRAPHICS The Five W ’s of Behavioral Health Care Documentation . . . . . . . . . . 3 INSTRUCTIVE INFOGRAPHICS Types of Behavioral Health Care Documentation . . . . . . . . . . . . . . . . 4 EXCERPTS THAT EXPLAIN A Complete Clinical/Case Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 PARTICULAR POINTS Dated and Authorized Orders . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6

SECTION SETS The Cyclical Process of Care, Treatment, or Services CONCISE CONCEPTS Care, Treatment, or Services as an Integrated System . . . . . . . . . . . . 7 INSTRUCTIVE INFOGRAPHICS Elements of the Care, Treatment, or Services Cyclical Process . . . . . 8 PARTICULAR POINTS Duration and Methods of Data Collection . . . . . . . . . . . . . . . . . . . . . . . 8 INSTRUCTIVE INFOGRAPHICS Data Analysis of the Individual’s Behavior . . . . . . . . . . . . . . . . . . . . . . . 9 CONCISE CONCEPTS Ongoing Action Planning Based on Data . . . . . . . . . . . . . . . . . . . . . . 10 INSTRUCTIVE INFOGRAPHICS Action Implementation Review and Process Restart . . . . . . . . . . . . 10 PARTICULAR POINTS Separation of a Continuous Process . . . . . . . . . . . . . . . . . . . . . . . . . . 11

SECTION SETS Core Steps of Care, Treatment, or Services INSTRUCTIVE INFOGRAPHICS Step-by-Step Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . 13 CONCISE CONCEPTS The Same Steps Across Behavioral Health Care . . . . . . . . . . . . . . . . 14 EXCERPTS THAT EXPLAIN Relationship of Core Steps to the Cyclical Process . . . . . . . . . . . . . . 14 INSTRUCTIVE INFOGRAPHICS Purpose of Documentation in the Core Steps . . . . . . . . . . . . . . . . . . 15

SECTION SETS Support for the Care, Treatment, or Services System PARTICULAR POINTS Joint Commission Standards and Behavioral Health Care  Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 INSTRUCTIVE INFOGRAPHICS Principles and Practices in Behavioral Health Care  Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 PARTICULAR POINTS Documentation of Support Processes . . . . . . . . . . . . . . . . . . . . . . . . . 18

SECTION SETS Effective, Quality Documentation PARTICULAR POINTS Formats of Behavioral Health Care Documentation . . . . . . . . . . . . . 19 FOCUS ON FAQS Records and Documentation: Format/Availability . . . . . . . . . . . . . . . 20 PARTICULAR POINTS Standardization of Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20 TOOLS TO TRY Electronic Health Record Decision Checklist . . . . . . . . . . . . . . . . . . . 21 PARTICULAR POINTS Policies for Security and Retention of Documentation . . . . . . . . . . . 21 EXCERPTS THAT EXPLAIN Integrity and Security of Documentation . . . . . . . . . . . . . . . . . . . . . . . 22 CONCISE CONCEPTS Documentation Policies and Procedures . . . . . . . . . . . . . . . . . . . . . . . 22 TOOLS TO TRY Policies and Procedures Evaluation Checklist . . . . . . . . . . . . . . . . . . 22

iv

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

INSTRUCTIVE INFOGRAPHICS Characteristics of Effective Documentation . . . . . . . . . . . . . . . . . . . . 23 PARTICULAR POINTS Quality Documentation for Evaluation of Practices and Progress . . 24 TOOLS TO TRY Outcomes Measurement Tracer Questions . . . . . . . . . . . . . . . . . . . . . 24

SUCCESSFUL STRATEGIES Measurement-Based Behavioral Health Care . . . . . . . 25

SCENARIOS TO STUDY Moving from Paper to Electronic Documentation . . . . . . . 28

CHAPTER 2

Documentation of Screening and Assessment of Care, Treatment, or Services . . 33

SECTION SETS Initial Screening and Assessment CONCISE CONCEPTS Pinpointing the Type and Level of Care . . . . . . . . . . . . . . . . . . . . . . . . 35 INSTRUCTIVE INFOGRAPHICS Screening Versus Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35 TOOLS TO TRY Screening and Assessment Tool Evaluation Checklist . . . . . . . . . . . 36 INSTRUCTIVE INFOGRAPHICS Initial Screening Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 PARTICULAR POINTS Specific Behavioral/Emotional Screening Data. . . . . . . . . . . . . . . . . . 37 EXCERPTS THAT EXPLAIN Effects of Trauma, Abuse, Neglect, or Exploitation . . . . . . . . . . . . . . 37 PARTICULAR POINTS Screening for Risk of Harm and Abuse, Neglect,  Trauma, or Exploitation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 TOOLS TO TRY Risk-of-Harm Screening Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 INSTRUCTIVE INFOGRAPHICS Characteristics of Effective Suicide Screening Tools . . . . . . . . . . . . . 39 TOOLS TO TRY Suicide Risk Assessment Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 TOOLS TO TRY Suicide Risk Assessment Tracer Questions . . . . . . . . . . . . . . . . . . . . 40 PARTICULAR POINTS Environmental Risks for Suicide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 EXCERPTS THAT EXPLAIN The Information to Be Collected . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 INSTRUCTIVE INFOGRAPHICS Initial Screenings Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 PARTICULAR POINTS Screening and Assessment at Intense Levels of Care,  Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 CONCISE CONCEPTS Influence of Requirements on Screening and  Assessment Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42

SECTION SETS Physical Screening and Assessment CONCISE CONCEPTS Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44 INSTRUCTIVE INFOGRAPHICS Requirements for Physical Assessment . . . . . . . . . . . . . . . . . . . . . . . . 44 INSTRUCTIVE INFOGRAPHICS Physical Health Screenings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 FOCUS ON FAQS H&P Content for Behavioral Health Care . . . . . . . . . . . . . . . . . . . . . . . 48 PARTICULAR POINTS H&P Admissions Data for Outcomes Measurement in  Eating Disorders Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48 PARTICULAR POINTS Physical Screening and Assessment for  Outdoor/Wilderness Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 TOOLS TO TRY Physical Health Screening and Examination Forms . . . . . . . . . . . . . . 49 PARTICULAR POINTS Coordinating Nonphysician and Physician Reports . . . . . . . . . . . . . . 49 CONCISE CONCEPTS Consequences of Physical Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 PARTICULAR POINTS Screening for Physical Pain . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 TOOLS TO TRY Physical Pain Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . 50

v

SECTION SETS Behavioral/Emotional Screening and Assessment CONCISE CONCEPTS Continuation of Initial Behavioral/Emotional Assessment . . . . . . . . . 51 INSTRUCTIVE INFOGRAPHICS Follow-Up Behavioral/Emotional Assessments . . . . . . . . . . . . . . . . . 52 TOOLS TO TRY Behavior Screening Checklist for ID/DD Programs . . . . . . . . . . . . . . 53 TOOLS TO TRY Behavioral/Emotional Assessment Form . . . . . . . . . . . . . . . . . . . . . . . 53

SECTION SETS Other Assessment Data CONCISE CONCEPTS Complicated Cases . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54 INSTRUCTIVE INFOGRAPHICS Potentially Relevant Assessment Elements . . . . . . . . . . . . . . . . . . . . . 55 INSTRUCTIVE INFOGRAPHICS Strength Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56 TOOLS TO TRY Strength Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . 56 PARTICULAR POINTS Strengths as Recovery Capital . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 INSTRUCTIVE INFOGRAPHICS Cultural Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 EXAMPLES TO EXAMINE Cultural Contributions to Conditions and Progress . . . . . . . . . . . . . . 59 INSTRUCTIVE INFOGRAPHICS Considering Age/Generation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 PARTICULAR POINTS Spiritual Assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60 TOOLS TO TRY Spiritual Assessment Questionnaire . . . . . . . . . . . . . . . . . . . . . . . . . . . 61 EXAMPLES TO EXAMINE Spiritual Assessments from a Completed Questionnaire . . . . . . . . . 61

SECTION SETS Analysis of Assessment Data EXCERPTS THAT EXPLAIN Accurately Identifying Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62 CONCISE CONCEPTS Consolidation of Information for Evaluation . . . . . . . . . . . . . . . . . . . . 63 INSTRUCTIVE INFOGRAPHICS Elements of a Diagnostic Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . 63 PARTICULAR POINTS The Need for a Statement of Needs . . . . . . . . . . . . . . . . . . . . . . . . . . . 64 INSTRUCTIVE INFOGRAPHICS Prioritizing Needs for a Statement of Needs . . . . . . . . . . . . . . . . . . . . 64 TOOLS TO TRY Diagnostic Summary Form and Statement of Needs Form . . . . . . . 65

SECTION SETS Screening and Assessment Challenges PARTICULAR POINTS Common Problems in Behavioral Health Care Screening and  Assessment Documentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66 CONCISE CONCEPTS Variability of Outcomes from Similar Data . . . . . . . . . . . . . . . . . . . . . . 66 INSTRUCTIVE INFOGRAPHICS Assessment Versus Summation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 PARTICULAR POINTS Documenting Verbal Assessment Discussions . . . . . . . . . . . . . . . . . . 68 PARTICULAR POINTS Clear, Precise, and Accurate Language . . . . . . . . . . . . . . . . . . . . . . . . 68 EXAMPLES TO EXAMINE Analysis Written in Clear Language . . . . . . . . . . . . . . . . . . . . . . . . . . . 69 PARTICULAR POINTS Difficulty of Assessment Posed by Substance Abuse . . . . . . . . . . . . 70

SUCCESSFUL STRATEGIES Screening and Assessment for  Trauma/Abuse in Substance Use Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 71

SCENARIOS TO STUDY Revising Documentation for Requirements  and Improvement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74

vi

Documentation of Care, Treatment, or Services IN BEHAVIORAL HEALTH CARE | Your Go-To Guide

CHAPTER 3

Documentation of Planning, Delivery, and Continuity of Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77

SECTION SETS Planning of Care, Treatment, or Services CONCISE CONCEPTS A Well-Developed Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78 INSTRUCTIVE INFOGRAPHICS Documenting Goals and Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 INSTRUCTIVE INFOGRAPHICS Defining Dates for Goals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80 CONCISE CONCEPTS Specific, Measurable Objectives . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PARTICULAR POINTS Documenting Planned Interventions . . . . . . . . . . . . . . . . . . . . . . . . . . 81 PARTICULAR POINTS Using Practice Guidelines to Develop the Plan . . . . . . . . . . . . . . . . . 82 INSTRUCTIVE INFOGRAPHICS The Individual’s Participation in Planning . . . . . . . . . . . . . . . . . . . . . . . 82 EXAMPLES TO EXAMINE Documentation of the Individual’s Participation . . . . . . . . . . . . . . . . . 83 TOOLS TO TRY Coping Strategies Preferences Form . . . . . . . . . . . . . . . . . . . . . . . . . . 84 INSTRUCTIVE INFOGRAPHICS Clinical/Case Record Versus Plan for Care, Treatment, or Services . . 84 TOOLS TO TRY Plan for Care, Treatment, or Services . . . . . . . . . . . . . . . . . . . . . . . . . 85

SECTION SETS Delivery of Care, Treatment, or Services CONCISE CONCEPTS A Sequence of “Mini-Plans” . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 86 INSTRUCTIVE INFOGRAPHICS Documenting Responses to Interventions . . . . . . . . . . . . . . . . . . . . . . 87 PARTICULAR POINTS Documentation for Coordination of Care, Treatment, or Services . . 87 CONCISE CONCEPTS Sequential Narratives on Progress . . . . . . . . . . . . . . . . . . . . . . . . . . . . 88 INSTRUCTIVE INFOGRAPHICS Progress Notes Versus Process Notes. . . . . . . . . . . . . . . . . . . . . . . . . 88 PARTICULAR POINTS Collaborative Progress Notes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 TOOLS TO TRY Progress Note Form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 INSTRUCTIVE INFOGRAPHICS Progress Notes as Cues for Plan Revision . . . . . . . . . . . . . . . . . . . . . . 90

SECTION SETS Continuity of Care, Treatment, or Services CONCISE CONCEPTS Continuity at Transfer or Discharge . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 INSTRUCTIVE INFOGRAPHICS Documenting Discharge Activities . . . . . . . . . . . . . . . . . . . . . . . . . . . . 92 PARTICULAR POINTS Discharge Planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93 INSTRUCTIVE INFOGRAPHICS Documentation of Needs for a Continuing Plan for Care,  Treatment, or Services . . .